Impulse control disorder
What Is an Impulse Disorder?
Many people act on impulse from time to time. However, there are some people who are impulsive to a significant degree, and meet the criteria for an impulsive disorder. According to the DSM-IV-TR, individuals who have impulse control disorders are unable to resist or control the urge, temptation, or drive to do something that causes harm to themselves or to someone else. The act is not something the person planned in advance.
Before engaging in the behavior, individuals with these disorders they may experience a growing sense of tension or arousal. When they act on the impulse, it gives them a sense of pleasure, relief or gratification. In some cases they may feel guilt or regret afterwards.
Types of Impulse Disorders
There are several psychiatric disorders that often include difficulties with impulse control as part of the clinical picture. These disorders also involve many other maladaptive thoughts and behaviors in order to qualify for a diagnosis. Included in this list are:
• Substance-related disorders
• Paraphilias (e.g., pedophilia, fetishism)
• Antisocial personality disorder
• Borderline personality disorder
• Conduct disorder
• Bipolar disorder (during a manic episode)
However, the DSM also lists several disorders under the specific category, “Impulse-Control Disorders not Elsewhere Classified”. These disorders have many similarities, yet are also significantly different in many ways.
• Intermittent Explosive Disorder (angry and / or violent outburst)
• Kleptomania (stealing)
• Pyromania (fire setting)
• Pathological Gambling
• Trichotillomania (pulling out one’s hair or eyelashes)
With each of these disorders, loss of control regarding a specific type of behavior is what defines them. This article will discuss this group of impulsive disorders specifically.
Intermittent Explosive Disorder
Individuals with intermittent explosive disorder are unable to control aggressive urges to assault someone or destroy property. This disorder is often seen in people who commit acts of road rage or domestic violence. They may throw things or break them. They often cause serious physical injury or damage. Others know them as someone with a serious temper that is out of control.
The aggressive behavior is a pattern, not just a singular episode. It is typically a gross over-reaction to the situation or stressor that triggered it.
After the explosive episode, the person may have feelings of embarrassment, regret, or remorse. However, it is not uncommon for individuals with this disorder to blame their outburst on their victims or situational factors. This lessens the guilt and often keeps them from seeking treatment in order to change.
Intermittent explosive disorder often has serious consequences for those who have it. Their explosive episodes may cost them their job or their marriage. It may land them in jail or prison. They may also end up in the hospital following an accident (such as a car accident during road rage) or a physical altercation.
This diagnosis is given only after other psychiatric disorders that may better account for the behavior are ruled out. Other disorders that may at times involve acts of rage or violent behavior include antisocial personality disorder, Borderline Personality Disorder, mania due to bipolar disorder or schizoaffective disorder, a psychotic disorder, conduct disorder or ADHD. The aggressive behavior must not be due to a medical condition, such as Alzheimer’s or a head injury. Also, the diagnosis is not given if the person’s violent outbursts are caused by his or her use of a substance, such as alcohol, drugs, or a medication.
Intermittent explosive disorder occurs more frequently in males than females. Symptoms also tend to surface a few years earlier in males than females. While once believed to be rare, recent research suggests that this disorder may affect as many as 5% to 11% of the U.S. population at some point in their lifetime.
Kleptomania involves the continuous failure to resist the impulse to steal items that are not for personal use or monetary value. The objects are also not stolen as a way to get back at someone or out of anger. The individual often experiences mounting tension prior to committing the act. Stealing provides a fleeting sense of pleasure or gratification, or relief from anxiety. In some ways, this disorder is similar to obsessive-compulsive disorder (OCD) – the behavior relieves tension. However, in OCD, the person does not usually get any gratification from the behavior.
People with kleptomania do not steal out of disregard for the law. In fact, they know that what they are doing makes no sense and isn’t right. They often do not seek treatment due to the guilt and shame they feel.
Contrary to popular belief, people who make a career out of stealing typically do not have kleptomania. Individuals who steal out of desperation or need, to support a gambling or substance abuse problem, or who do so for fun or just because they know they can get away with it, also do not fit the clinical picture of kleptomania. Individuals in the latter group are more likely to have a diagnosis of conduct disorder or antisocial personality disorder, and feel laws don’t apply to them.
Kleptomania is quite rare, even amongst shoplifters. This disorder occurs much more frequently in females than in males. There is no cure for this disorder, but psychotherapy may help the person learn ways to manage the impulse.
Individuals who have pyromania have a history that involves multiple incidences of intentional fire setting. There is no logical motive for the behavior. Prior to setting a fire, they often experience tension or emotional arousal of some sort. Pyromaniacs are drawn to fire out of interest, curiosity, fascination, or an attraction to fire and things associated with it – the consequences of fire, uses of fire, or fire paraphernalia.
When people with pyromania set fires, they experience pleasure, relief from tension, or gratification. They may also experience these things just from watching a fire (e.g. a fire in their neighborhood) or by participating in the events following a fire, such as helping to put it out or cleaning up the mess. In fact, someone with this disorder may be drawn to a career as a firefighter.
Pyromaniacs do not set fires for financial gain (e.g. to obtain insurance reimbursement), to make a political statement (e.g. burning down an abortion clinic), to get revenge, to cover up a crime, or to make their life better in some way. They do not set fires due to psychosis, dementia, mental retardation, or because they are intoxicated. Individuals with conduct disorder, antisocial personality disorder, or mania may set a fire as part of their disorder – in those cases a diagnosis of pyromania is not made.
Pyromania is quite rare. Sadly, the consequences of this disorder can be very serious and even deadly, as fire setting often results in significant property damage and may cause loss of life.
While many people enjoy going to a casino and playing the slots or other games from time to time, or enjoy betting on a horse race or poker game, they aren’t pathological gamblers. Individuals with this disorder are unable to control the urge to gamble despite the significant degree such maladaptive behavior is disrupting their life.
Pathological gamblers are often preoccupied with gambling. They may relive past wins or losses or spend a lot of time planning their next gambling outing. They may also spend a lot of time trying to come up with ways to finance their gambling habit. They often get a type of “high” from gambling – even more than from winning money.
As with other addictions, pathological gamblers continue gambling even though they may have tried numerous times quit, cut back, or control their gambling. During such attempts they may become irritable or restless. For them, gambling is often a way to avoid dealing with problems or to relieve negative emotions. They often hide this problem from others, and may lie to spouses, family members, friends and even their therapist about their gambling.
Pathological gamblers often develop a pattern of chasing their losses. Their bets become riskier and bigger in a desperate attempt to make up for money they have lost. It is not uncommon for individuals with this disorder to be superstitious or have distorted thought patterns, such as denial about their problem, overconfidence in their ability to win, or a feeling of power and control. They are often high energy individuals who are very competitive, easily bored, and often restless. They also tend to regard money as the cause of all their problems, as well as the way to solve them.
Individuals with this disorder are often workaholics. Many of them have stress-related medical conditions such as high blood pressure or ulcers. It is not unusual for them to have another psychiatric disorder as well, particularly a personality disorder (borderline, narcissistic, or antisocial), a mood disorder, ADHD, or a problem with substance abuse or dependence. Suicide attempts are not uncommon with this particular population.
The majority of pathological gamblers are males, but there are many women with this problem as well. Women are more inclined to gamble as a way to escape depression. Sadly, pathological gambling is found in a significant number of adults. Although some people are instantly “hooked”, in most cases this disorder develops gradually.
The consequences of pathological gambling can be severe. It often causes significant financial problems or even financial ruin. Marriages break up and jobs are often lost due to pathological gambling. Individuals with this disorder may even resort to criminal behavior to fund their gambling, such as embezzlement, theft, forgery or fraud. These actions can lead to serious legal problems including prison time.
People with trichotillomania repeatedly pull out their hair to the point of having a noticeable loss of hair. While the hair may be anywhere on their body, the most common areas are the scalp, eyelashes, and eyebrows. They often experience increased tension just before they start pulling out their hair – the behavior brings a sense of relief, gratification, or pleasure. If they try to resist the urge, the tension gets worse.
Individuals with trichotillomania don’t pull their hair out due to any type of medical condition, or as a result of another psychiatric disorder. In adults, this disorder occurs more frequently in women. However, in children it occurs about equally in both genders. Although once thought to be quite rare, it actually occurs somewhat frequently.
Trichotillomania causes significant distress and / or impairment in a person’s life. It can lead to many complications. For example, hair follicles are destroyed when someone frequently pulls their hair out. As a result, their hair won’t grow back. The hair pulling can also aggravate the scalp. Some individuals even develop carpal tunnel syndrome due to the repetitive movement. Some individuals with trichotillomania also eat their hair. This is known as tricophagia. It can cause them to develop a large hairball, which, over time may lead to problems such as vomiting and weight loss. A hairball of this type can block the intestines and ultimately be fatal.
Getting a haircut can be distressing for someone with trichotillomania. There is often a lot of shame tied to the disorder, causing them to want to avoid such situations. Windy days may also be distressing. Many people with this disorder wear wigs to hide bald patches on their scalp. If they pull out their eyelashes, they may resort to wearing false eyelashes. Needless to say, the embarrassment, shame, and low self-esteem that often accompany the disorder may adversely affect relationships, prevent intimacy, and even cause some to attempt suicide.
Causes of Impulse-control Disorders
The cause of most impulse-control disorders is not really known. However, there is research that suggests that lack of impulse behavior may have something to do with various neurotransmitters, particularly serotonin, but also dopamine and norepinephrine.
For example, impulsive aggressive behavior is linked to low serotonin levels. Serotonin plays a role in the regulation of mood and emotions.
Genetics may also play a role in the development of impulse disorder. For example, research suggests that trichotillomania may be in part caused by the mutation of a particular gene.
Impulsive disorders may also stem from a pre-disposition. This may be related to other disorders such as mood disorders, personality disorders, and substance abuse disorders. However, a diagnosis of any of the impulse control disorders is not given if the behavior is better accounted for by another psychiatric disorder or medical condition.
Treatment for Impulse Disorders
There are no actual “cures” for any of the impulse-control disorders. Considering the potentially serious, if not deadly (e.g. with intermittent-explosive disorder and pyromania) consequences of these disorders, getting the appropriate treatment is important. Unfortunately, many individuals with these disorders don’t seek treatment, either due to the shame or because they don’t really want treatment.
In general, a combination of medication and psychotherapy is usually the recommended treatment for these disorders. Medications may involve the SSRIs, which target serotonin, other types of antidepressants, anti-anxiety medications, anti-convulsants, and mood stabilizers.
Psychotherapy, particularly cognitive behavioral therapy (CBT) has been shown to be helpful in the treatment of impulse-control disorders. CBT focuses on the relationship between one’s thoughts, feelings and behaviors. CBT may help the person find ways to control the impulse.
For people with intermittent-explosive disorder, anger management may be useful in helping them control their angry emotions. Also, learning relaxation techniques and other types of coping skills may also be beneficial.
Individuals with pathological gambling may benefit from a group such as Gambler’s Anonymous.
Impulsive disorders typically wreak havoc in the lives of those who have them, as well as the lives of those around them. If you or a loved one has difficulties with any of the types of impulses listed above, then you should definitely consider seeking treatment. Enduring the shame or dealing with serious consequences does not have to always be part of your life.